DailyMed Label: POSIMIR

DailyMed Label: POSIMIR

2022

DailyMed Prescription

POSIMIR

bupivacaine

INNOCOLL PHARMACEUTICALS

NDC: 51715-660

NDC: 51715-660

POSIMIR (bupivacaine solution) is a sterile nonpyrogenic, clear, light yellow to amber solution for infiltration. Over time, the solution color will intensify within the range, from light yellow to amber. The range of color is not associated with a change in potency of the drug product. POSIMIR contains bupivacaine (132 mg/mL), benzyl alcohol, and sucrose acetate isobutyrate. Bupivacaine, an amide-type local anesthetic, is 1-butyl-N-(2,6-dimethylphenyl)-2-piperidinecarboxamide. It is a white crystalline powder with a molecular weight of 288.43 g/mol. The structure of bupivacaine is shown below: Bupivacaine is present in POSIMIR at a concentration of 132 mg/mL. Structure of Bupivacaine

POSIMIR is indicated in adults for administration into the subacromial space under direct arthroscopic visualization to produce post-surgical analgesia for up to 72 hours following arthroscopic subacromial decompression. POSIMIR contains an amide local anesthetic and is indicated in adults for administration into the subacromial space under direct arthroscopic visualization to produce post-surgical analgesia for up to 72 hours following arthroscopic subacromial decompression. Limitations of Use Safety and effectiveness have not been established in other surgical procedures, including soft tissue surgical procedures, other orthopedic procedures, including for intra-articular administration, and boney procedures, or when used for neuraxial or peripheral nerve blockade. Limitations of Use Safety and effectiveness have not been established in other surgical procedures, including soft tissue surgical procedures, other orthopedic procedures, including for intra-articular administration, and boney procedures, or when used for neuraxial or peripheral nerve blockade.

For single-dose administration only. ( 2.1 ) Do not dilute or mix with local anesthetics or other drugs or diluents. . ( 2.1 ) Do not convert from other bupivacaine formulations to POSIMIR. Do not substitute. ( 2.1 ) Avoid additional use of local anesthetics within 168 hours following administration of POSIMIR. The recommended dose is 660 mg (5 mL). ( 2.2 ). See Full Prescribing Information for additional dosage and administration instructions and compatibility considerations. ( 2.3 , 2.4 ) POSIMIR is intended for single-dose administration only. Do not dilute or mix POSIMIR with local anesthetics or other drugs or diluents. As there is a potential risk of severe, life-threatening adverse reactions associated with the administration of bupivacaine, POSIMIR should be administered in a setting where trained personnel and equipment are available to promptly treat patients who show evidence of neurological or cardiac toxicity. Different formulations of bupivacaine are not bioequivalent to POSIMIR even if the milligram dosage is the same. It is not possible to convert dosing from any other formulations of bupivacaine to POSIMIR and vice versa. Do not substitute. The toxic effects of local anesthetics are additive. Avoid additional use of local anesthetics within 168 hours following administration of POSIMIR. Avoid intravascular administration of POSIMIR. Convulsions and cardiac arrest have occurred following accidental intravascular injection of bupivacaine and other amide-containing products. POSIMIR is not indicated for the following routes of administration. Epidural Intrathecal Intravascular Intra-articular use [see Nonclinical Toxicology ( 13.2 )] Regional nerve blocks Pre-incisional or pre-procedural locoregional anesthetic techniques that require deep and complete sensory block in the area of administration. The recommended dose of POSIMIR is 660 mg (5 mL). POSIMIR is ready to use and does not require dilution or mixing. Prior to administration, draw up POSIMIR into a 5 mL syringe using a large bore needle (16 gauge or larger). Once the syringe has been filled, discard the large bore needle. At the close of surgery, administer the entire 5 mL dose of POSIMIR into the subacromial space using an 18 gauge or larger-bore needle. The needle may be inserted through an existing arthroscopic port or through intact skin to reach the subacromial space. Confirm correct placement of the needle tip within the subacromial space by direct arthroscopic visualization. Do not administer POSIMIR into the glenohumeral intra-articular space. POSIMIR is compatible with: Commonly implantable materials, such as polypropylene and polyester Silk, nylon, gut, polypropylene, polydioxanone, and polyglycolic acid sutures

POSIMIR (bupivacaine solution) is a sterile, nonpyrogenic, clear, light yellow to amber solution in a clear, glass vial. 5 mL single-dose vial: 660 mg/5 mL (132 mg/mL) Solution: 5 mL single-dose vial, 660 mg/5 mL (132 mg/mL) ( 3 ).

POSIMIR is contraindicated in: Patients with a known hypersensitivity (e.g. anaphylactic reactions and serious skin reactions) to any amide local anesthetic, or other components of POSIMIR. Patients undergoing obstetrical paracervical block anesthesia. The use of bupivacaine HCl with this technique has resulted in fetal bradycardia and death. Patients with a known hypersensitivity (e.g. anaphylactic reactions and serious skin reactions) to any amide local anesthetic, or other components of POSIMIR. Patients undergoing obstetrical paracervical block anesthesia ( 4 ).

Risk of Joint Cartilage Necrosis with Unapproved Intra-articular Use: A study evaluating the effects of POSIMIR and POSIMIR vehicle in dogs following an intra-articular administration demonstrated joint cartilage necrosis ( 5.2 , 13.2 ). Risk of Systemic Toxicity : Careful and constant monitoring of cardiovascular and respiratory (adequacy of ventilation) vital signs and the patient's state of consciousness should be performed after injection of bupivacaine. ( 5.3 ) Methemoglobinemia : Cases of methemoglobinemia have been reported in association with local anesthetic use. See Full Prescribing Information for more detail on managing these risks. ( 5.4 ) Chondrolysis with Intra-Articular Infusion : Intra-articular infusions of local anesthetics including POSIMIR following arthroscopic and other surgical procedures is an unapproved use, and there have been post-marketing reports of chondrolysis in patients receiving such infusions. ( 5.5 ) Inadvertent intravascular injection could cause POSIMIR droplets to be deposited in the pulmonary and other capillary beds. Administer POSIMIR into the subacromial space at the end of arthroscopic shoulder surgery. Direct arthroscopic visualization must be used to confirm proper placement of the needle tip before injecting POSIMIR. The safety and effectiveness of POSIMIR in surgical procedures other than subacromial decompression have not been established, and POSIMIR is not approved for use via intra-articular injection. A study evaluating the effects of POSIMIR and POSIMIR vehicle in dogs following an intra-articular administration demonstrated joint cartilage necrosis [ see Nonclinical Toxicology ( 13.2 ) ]. Unintended intravascular injection of POSIMIR may be associated with systemic toxicities, including CNS or cardiorespiratory depression and coma, progressing ultimately to respiratory arrest. Direct arthroscopic visualization must be used to confirm proper placement of the needle tip in the subacromial space before injecting POSIMIR. The safety and effectiveness of bupivacaine depend on proper dosage, correct technique, adequate precautions, and readiness for emergencies. Careful and constant monitoring of cardiovascular and respiratory (adequacy of ventilation) vital signs and the patient's state of consciousness should be performed after injection of bupivacaine. Possible early warning signs of central nervous system (CNS) toxicity are restlessness, anxiety, incoherent speech, lightheadedness, numbness and tingling of the mouth and lips, metallic taste, tinnitus, dizziness, blurred vision, tremors, twitching, CNS depression, or drowsiness. Delay in proper management of systemic toxicity, underventilation from any cause, and/or altered sensitivity may lead to the development of acidosis, cardiac arrest, and, possibly, death. Avoid additional use of local anesthetics within 168 hours following administration of POSIMIR. Injection of repeated doses of bupivacaine may cause significant increases in plasma levels due to slow accumulation of the drug or its metabolites, or to slow metabolic degradation. Tolerance to elevated blood levels varies with the status of the patient. Consider increased monitoring for systemic toxicity in debilitated, elderly, or acutely ill patients. Cases of methemoglobinemia have been reported in association with local anesthetic use. Although all patients are at risk for methemoglobinemia, patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, infants under 6 months of age, and concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing clinical manifestations of the condition [ see Drug Interactions ( 7 ) ]. If local anesthetics must be used in these patients, close monitoring for symptoms and signs of methemoglobinemia is recommended. Signs of methemoglobinemia may occur immediately or may be delayed some hours after exposure, and are characterized by a cyanotic skin discoloration and/or abnormal coloration of the blood. Methemoglobin levels may continue to rise; therefore, immediate treatment is required to avert more serious central nervous system and cardiovascular adverse effects, including seizures, coma, arrhythmias, and death. Discontinue any oxidizing agents. Depending on the severity of the signs and symptoms, patients may respond to supportive care, i.e., oxygen therapy, hydration. A more severe clinical presentation may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen. Intra-articular infusions of local anesthetics including bupivacaine following arthroscopic and other surgical procedures is an unapproved use, and there have been post-marketing reports of chondrolysis in patients receiving such infusions. The majority of reported cases of chondrolysis have involved the shoulder joint; cases of gleno-humeral chondrolysis have been described in pediatric patients and adult patients following intra-articular infusions of local anesthetics with and without epinephrine for periods of 48 to 72 hours. There is insufficient information to determine whether shorter infusion periods are associated with chondrolysis. The time of onset of symptoms, such as joint pain, stiffness, and loss of motion can be variable, but may begin as early as the second month after surgery. Currently, there is no effective treatment for chondrolysis; patients who have experienced chondrolysis have required additional diagnostic and therapeutic procedures and some required arthroplasty or shoulder replacement. Because amide local anesthetics such as bupivacaine are metabolized by the liver, consider reduced dosing and increased monitoring for bupivacaine systemic toxicity in patients with moderate to severe hepatic impairment who are treated with POSIMIR [see Use in Specific Populations ( 8.6 ) ]. Care should be taken when considering the use of POSIMIR in patients with impaired cardiovascular function (e.g., hypotension, heartblock) because they may be less able to compensate for functional changes associated with the prolongation of AV conduction produced by bupivacaine. Consider reduced dosing. Monitor patients closely for blood pressure, heart rate, and ECG changes.

The following adverse reactions to bupivacaine hydrochloride are described in other sections of the prescribing information:

Do not dilute or mix POSIMIR with local anesthetics or other drugs or diluents. Avoid additional use of local anesthetics within 168 hours following administration of POSIMIR. Patients who are administered POSIMIR are at increased risk of developing methemoglobinemia when concurrently exposed to following drugs, which could include other local anesthetics [see Warnings and Precautions ( 5.4 )]. Examples of Drugs Associated with Methemoglobinemia: Class Examples Nitrates/Nitrites nitric oxide, nitroglycerin, nitroprusside, nitrous oxide Local anesthetics articaine, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, tetracaine Antineoplastic agents cyclophosphamide, flutamide, hydroxyurea, ifosfamide, rasburicase Antibiotics dapsone, nitrofurantoin, para-aminosalicylic acid, sulfonamides Antimalarials chloroquine, primaquine Anticonvulsants phenobarbital, phenytoin, sodium valproate Other drugs acetaminophen, metoclopramide, quinine, sulfasalazine

Moderate to Severe Hepatic Impairment : Consider reduced dosing and increased monitoring for bupivacaine toxicity. ( 8.6 ) Risk Summary There are no studies conducted with POSIMIR in pregnant women. In animal studies, embryo-fetal lethality was noted when bupivacaine was administered subcutaneously to pregnant rabbits during organogenesis at 0.6 times the maximum recommended human dose of POSIMIR at 660 mg bupivacaine. Decreased pup survival was observed in a rat pre- and post-natal development study (dosing from implantation through weaning) at 0.6 times the maximum recommended human dose of POSIMIR at 660 mg bupivacaine. Based on animal data, advise pregnant women of the potential risks to a fetus. [see Data ] The background risk of major birth defects and miscarriage for the indicated population is unknown. However, the background risk in the U.S. general population of major birth defects is 2%-4% and of miscarriage is 15%-20% of clinically recognized pregnancies. Clinical Considerations Labor or Delivery Bupivacaine is contraindicated for obstetrical paracervical block anesthesia. While POSIMIR has not been studied with this technique, the use of bupivacaine for obstetrical paracervical block anesthesia has resulted in fetal bradycardia and death. Bupivacaine can rapidly cross the placenta, and when used for epidural, caudal, or pudendal block anesthesia, can cause varying degrees of maternal, fetal, and neonatal toxicity (POSIMIR is not indicated for these uses). The incidence and degree of toxicity depend upon the procedure performed, the type, and amount of drug used, and the technique of drug administration. Adverse reactions in the parturient, fetus, and neonate involve alterations of the central nervous system, peripheral vascular tone, and cardiac function. Data Animal Data Bupivacaine hydrochloride produced developmental toxicity when administered subcutaneously to pregnant rats and rabbits at clinically relevant doses. Bupivacaine hydrochloride was administered subcutaneously to rats at doses of 4.4, 13.3, & 40 mg/kg and to rabbits at doses of 1.3, 5.8, & 22.2 mg/kg during the period of organogenesis (implantation to closure of the hard palate). The high doses are approximately 0.6 times the daily maximum recommended human dose (MRHD) of 660 mg/day on a mg/m 2 body surface area (BSA) basis. No embryo-fetal effects were observed in rats at the high dose which caused increased maternal lethality. An increase in embryo-fetal deaths was observed in rabbits at the high dose in the absence of maternal toxicity with the fetal No Observed Adverse Effect Level representing approximately 0.2 times the MRHD on a BSA basis. In a rat pre- and post-natal developmental study (dosing from implantation through weaning) conducted at subcutaneous doses of 4.4, 13.3, & 40 mg/kg, decreased pup survival was observed at the high dose. The high dose is approximately 0.6 times the daily MRHD of 660 mg/day on a BSA basis. Risk Summary POSIMIR has not been studied in nursing mothers. Bupivacaine can persist in plasma for up to 168 hours [see Clinical Pharmacology ( 12 ) ] and benzyl alcohol, a POSIMIR excipient, for up to 12 hours after POSIMIR administration. Both bupivacaine and benzyl alcohol have been reported to be excreted in human milk. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for POSIMIR and any potential adverse effects on the breastfed infant from POSIMIR or from the underlying maternal condition. Safety and effectiveness of POSIMIR in pediatric patients below the age of 18 have not been established. Of the total number of patients enrolled in the POSIMIR clinical studies (N=1463), 167 patients were older than 65 years and 32 patients were older than 75 years. In bupivacaine clinical studies, differences in various pharmacokinetic parameters have been observed between elderly and younger adult patients. Bupivacaine is known to be substantially excreted by the kidney, and the risk of adverse reactions to bupivacaine may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. Elderly patients may require lower doses of POSIMIR. Consider increased monitoring for local anesthetic systemic toxicity when administering POSIMIR to elderly patients. Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, these drugs should be used with caution in patients with hepatic impairment. Patients with severe hepatic impairment, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations, and potentially local anesthetic systemic toxicity. Care should be taken when considering the use of POSIMIR in patients with impaired hepatic function and consider reduced dosing. Consider increased monitoring for local anesthetic systemic toxicity in patients with moderate to severe hepatic impairment when administering POSIMIR. Bupivacaine is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Care should be taken when considering the use of POSIMIR in patients with impaired renal function. Consider increased monitoring for local anesthetic systemic toxicity when administering POSIMIR to patients with impaired renal function.

POSIMIR (bupivacaine solution) is available in single‑dose vials. It is a sterile nonpyrogenic, clear, light yellow to amber solution in glass vials. 5 mL single-dose vial, 660 mg/5 mL (132 mg/mL) packaged in a 10-unit carton (NDC 51715-660-10 ) Storage POSIMIR vial should be stored at a controlled room temperature of 20°C to 25°C (68°F to 77°F), excursions permitted to 15°C to 30°C (59°F to 86°F). [See USP Controlled Room Temperature]. Vial should be protected from light and retained in carton until time of use. Handling Do not administer any solution which contains particulate matter. Do not autoclave. Do not dilute. Discard any unused portion in an appropriate manner. NDC No. Container Size Quantity NDC 51715-660-10 Single-dose vials 5 mL Box of 10

Bupivacaine blocks the generation and the conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve, by slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential. In general, the progression of anesthesia is related to the diameter, myelination and conduction velocity of affected nerve fibers. Clinically, the order of loss of nerve function is as follows: (1) pain, (2) temperature, (3) touch, (4) proprioception, and (5) skeletal muscle tone. Systemic absorption of bupivacaine produces effects on the cardiovascular and central nervous systems. At blood concentrations achieved with therapeutic doses, changes in cardiac conduction, excitability, refractoriness, contractility, and peripheral vascular resistance are minimal. However, toxic blood concentrations depress cardiac conduction and excitability, which may lead to atrioventricular block, ventricular arrhythmias and to cardiac arrest, sometimes resulting in fatalities. In addition, myocardial contractility is depressed and peripheral vasodilation occurs, leading to decreased cardiac output and arterial blood pressure. These cardiovascular changes are more likely to occur after unintended intravascular injection of liquid formulations of bupivacaine. Following systemic absorption, local anesthetics can produce central nervous system stimulation, depression or both. Apparent central stimulation is usually manifested as restlessness, tremors and shivering, progressing to convulsions, followed by depression and coma, progressing ultimately to respiratory arrest. However, the local anesthetics have a primary depressant effect on the medulla and on higher centers. The depressed stage may occur without a prior excited stage. Infiltration of POSIMIR into the surgical wound results in plasma levels of bupivacaine that can persist for 168 hours. Systemic plasma levels of bupivacaine following administration of POSIMIR are not correlated with local efficacy. Absorption The rate of systemic absorption of bupivacaine is dependent upon the total dose of drug administered, the route of administration, and the vascularity of the administration site. Pharmacokinetic parameters of bupivacaine are shown in Table 10 after single-dose infiltration of POSIMIR in arthroscopic subacromial decompression surgical procedure. Table 10. Summary of Pharmacokinetic Parameters for Bupivacaine after Administration of a Single Dose of POSIMIR 5 mL (660 mg) # t = last sampling time ^ Median / Range (min-max) * Drug leakage from the surgical site was suspected. Surgical Procedure C max (ng/mL) AUC 0-t # (h·ng/mL) T max (h) ^ T 1/2 (h) Arthroscopic subacromial decompression Study 1* N 36 36 36 36 Mean 593 19395 5.9 ^ 16.4 SD 299 12056 1.0-24.0 ^ 5.1 Arthroscopic subacromial decompression Study 3 N 18 18 18 18 Mean 1006 47015 8.0 ^ 26.1 SD 454 20040 2.1-26.9 ^ 8.2 Distribution Depending upon the route of administration, bupivacaine is distributed to some extent to all body tissues, with high concentrations found in highly perfused organs such as the liver, lungs, heart, and brain. Bupivacaine appears to cross the placenta by passive diffusion. The rate and degree of diffusion is governed by (1) the degree of plasma protein binding, (2) the degree of ionization, and (3) the degree of lipid solubility. Fetal/maternal ratios of local anesthetics appear to be inversely related to the degree of plasma protein binding, because only the free, unbound drug is available for placental transfer. Bupivacaine with a high protein binding capacity (95%) has a low fetal/maternal ratio (0.2 to 0.4). The extent of placental transfer is also determined by the degree of ionization and lipid solubility of the drug. Lipid soluble, non-ionized drugs such as bupivacaine readily enter the fetal blood from the maternal circulation. Elimination The mean half-life of bupivacaine after POSIMIR administration in adults who underwent arthroscopic subacromial decompression range from 16.4 to 26.1 hours. Metabolism Amide-type local anesthetics such as bupivacaine are metabolized primarily in the liver via conjugation with glucuronic acid. Pipecoloxylidine is the major metabolite of bupivacaine. The elimination of drug from tissue distribution depends largely upon the availability of binding sites in the circulation to carry it to the liver where it is metabolized. Excretion The kidney is the main excretory organ for most local anesthetics and their metabolites. Urinary excretion is affected by urinary perfusion and factors affecting urinary pH. Only 6% of bupivacaine is excreted unchanged in the urine. Specific Populations Hepatic Impairment Pharmacokinetics of POSIMIR have not been evaluated in patients with hepatic impairment. [see Warnings and Precautions ( 5 ) and Use in Specific Populations ( 8.6 ) ]. Renal Impairment Pharmacokinetics of POSIMIR have not been evaluated in patients with renal impairment. [see Use in Specific Populations ( 8.7 ) ]. Geriatric Patients Pharmacokinetics of POSIMIR have not been evaluated in geriatric patients. Elderly patients have exhibited higher peak plasma concentrations than younger patients following administration of bupivacaine HCl. The total plasma clearance was decreased in these patients [see Use in Specific Populations ( 8.5 )].

Carcinogenesis Long-term studies in animals to evaluate the carcinogenic potential of bupivacaine hydrochloride have not been conducted. Mutagenesis Bupivacaine was negative in the in vitro bacterial reverse mutation assay (Ames assay), the in vitro chromosomal aberration assay (human peripheral blood lymphocytes), and the in vivo rat micronucleus assay. Impairment of Fertility The effect of bupivacaine on fertility has not been determined. Necrosis of the joint cartilage was observed following intra-articular injection of a single dose of POSIMIR or POSIMIR vehicle in the dog model.

The effectiveness of POSIMIR was evaluated in ten adequate and well-controlled studies in patients undergoing open and laparoscopic abdominal procedures, abdominal hysterectomy, inguinal hernia repair, and open and arthroscopic shoulder procedures. Adequate evidence of effectiveness was demonstrated in one of three studies conducted in patients undergoing shoulder surgery (described in detail below) and was not demonstrated in any soft tissue procedure evaluated. Study 1 Study 1 was a randomized, multicenter, assessor blinded, placebo-controlled (vehicle) clinical trial in 107 patients undergoing arthroscopic subacromial decompression surgery with an intact rotator cuff. Associated procedures included inspection of the glenohumeral joint, distal clavicle excision, bursectomy, synovectomy, removal of loose body, resection of coracoacromial ligament and subacromial spurs, rotator cuff debridement, and minor debridement of articular cartilage. There were no open surgical procedures performed during this study. The mean age was 50 years (range 21 to 70 years), 60% of treated patients were female, 96% were White, 2% were Hispanic, 1% were Asian, and 1% were Other. Patients were randomized 2:1:1 to receive POSIMIR, vehicle placebo, or bupivacaine HCl 50 mg, and all patients received general anesthesia. No analgesic pre-medication or local anesthetics were administered. POSIMIR and vehicle placebo were administered under direct arthroscopic visualization as single injections into the subacromial space through one of the arthroscopic portals at the end of the surgery. Bupivacaine HCl 50 mg was administered subacromially as a single dose. Post-operatively, patients received acetaminophen 500 mg or 1000 mg every six hours, depending on body weight, through 72 hours, and were allowed morphine rescue medication as needed, either 2 mg IV or 10 mg orally. Pain intensity was rated by the patients using a 0 to 10 numerical rating scale (NRS) at multiple time points up to 72 hours. The primary outcome measures were the normalized area under the curve (nAUC) of mean pain intensity on movement scores collected at specified intervals over the first 72 hours after surgery and total opioid rescue analgesia (IV morphine-equivalent dose) through 72 hours. In this clinical study, POSIMIR 5 mL demonstrated a significant reduction in mean pain intensity compared with placebo of 1.3 points on a 0 to 10 NRS scale over 72 hours ( Figure 1 ). Figure 1. Mean Pain Intensity on Movement Through 72 Hours After Surgery, Subacromial Decompression Study 1 The median total use of opioid rescue analgesia (IV morphine equivalent dose) from 0 to 72 hours for the POSIMIR treatment group (4 mg) was statistically lower than for the placebo treatment group (12 mg). The median use of opioid rescue analgesia in the bupivacaine treatment group was 8 mg. Figure 1 Study 2 Study 2 was a randomized, double-blind, placebo-controlled (vehicle) clinical trial in 60 patients undergoing arthroscopic subacromial decompression, inspection of glenohumeral joint, synovectomy, removal of loose body, minor debridement of articular cartilage, minor debridement or minor repair of rotator cuff, open distal clavicle excision, bursectomy, and resection of coracoacromial ligament and subacromial spurs. The mean age was 48 years (range 27 to 68 years), 55% of treated patients were female, 95% were White, 2% were Asian, and 2% were Other. Patients were randomized 2:1 to receive POSIMIR or vehicle placebo, and all patients received general anesthesia. Post-operatively, patients were allowed morphine rescue medication as needed, either 3 mg IV or 10 mg to 15 mg orally, or acetaminophen. Pain intensity was rated by the patients using a 0 to 10 numerical rating scale (NRS) at multiple time points up to 72 hours. The primary outcome measures were mean pain intensity on movement AUC through 72 hours and total opioid rescue analgesia (IV morphine-equivalent dose) through 72 hours. There was no statistically significant difference in either primary endpoint between the POSIMIR and vehicle placebo treatment groups ( Figure 2 ). Figure 2: Mean Pain Intensity on Movement Through 72 Hours After Surgery, Subacromial Decompression Study 2 Figure 2 Study 3 Study 3 was a randomized, double-blind, placebo-controlled (vehicle) and open-label PK clinical trial in 92 patients undergoing a variety of shoulder surgical procedures, including rotator cuff repair, subacromial decompression, glenoid labrum repair or debridement, and biceps tendon repair. The majority of patients underwent arthroscopic procedures; however, six patients underwent a combination of arthroscopic and open procedures. The mean age was 54 years (range 20 to 82 years), 59% of treated patients were male, 87% were White, 8% were African American, 3% were Other, and 2% were Asian. An equal number of patients were randomized to two cohorts. The routes of POSIMIR or vehicle placebo administration in Cohort 1 were subacromial or subcutaneous injection or a combination. In Cohort 2, POSIMIR or vehicle placebo was administered via injection under direct arthroscopic visualization into the subacromial space. Surgical procedures were completed either under local or general anesthesia. Post-operatively, patients were allowed morphine IV, oxycodone orally, or acetaminophen orally as needed. The primary outcome measures were mean pain intensity on movement and at rest through 120 hours and pain control through day seven. There was no statistically significant difference in either primary endpoint between POSIMIR and vehicle placebo treatment groups ( Figure 3 ). Figure 3: Mean Pain Intensity on Movement Through 120 Hours After Surgery, Subacromial Decompression Study 3 Figure 3

Principal Display Panel - 5 mL Carton Label 5 mL vial x 10 vials per carton NDC 51715-660-10 Rx Only Posimir ® (bupivacaine solution) 660 mg/5 mL (132 mg/mL) FOR INFILTRATION Not for any other route of administration. Do not dilute. Principal Display Panel - 5 mL Carton Label